New Client Registration Form

New Client Registration Form

Thank you for choosing Safe Time Supervised Visitation. This intake form is designed to gather the necessary information to ensure a structured, and child-focused visitation experience. Please complete all sections accurately and thoroughly. Your responses help us provide the highest standard of services while remaining neutral, professional, and aligned with court expectations.
Please answer every question as thoroughly and accurately as possible, even if it doesn’t seem to apply. Incomplete forms slow down the process for everyone.
✅ Contact Information
Your relationship to child / protected person*
Your Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Other Parental Party Name / Phone Number / Email Address*
What method of communication do the custodial and non-custodial parties use? (App, text, email, phone, etc.)
How would you describe your current communication with the other parent?(Select the option(s) that best describes your situation.)

Good – We communicate respectfully and effectively.Fair – We have occasional disagreements but can still coordinate when needed.Strained – Communication is difficult, but we can exchange necessary information.Very Strained – Communication is minimal and often leads to conflict.No Contact – We do not communicate at all.Communication only through attorneys or third parties.This question does not apply to my situation
Type of supervised visit or service you are requesting (Check all that apply)*

In-Office Supervised Visitation – Willow Park, TX ($65/hour)Residential Home Supervised Visitation $85/hour – Sessions scheduled in two-hour blocks onlyCommunity Location Supervised Visitation $85/hour – Sessions scheduled in two-hour blocks onlyVirtual or Phone visitation $40/hour - 30 minute sessionReunification or Parenting Training $85/hourSafe Home Inspection $250 flat feePolice officer needed for safetyPre-Visitation Drug or Alcohol testing (starts at $30 per test)Case Management / Parent Coordinator (see website)Family Reentry Program (see website)
Existing Court Order*

Yes, I have a valid court order for supervised visitationNo, I do not have an order; mutual parenting agreementMy order is expiredThis question does not apply to my situation
Name, Email, & Phone Number of Your Attorney
If you have a court order requiring supervised visitation, please upload it here. You may submit clear photos of the relevant pages. VISITS CAN NOT BEGIN UNTIL THE COURT ORDER OR A MUTUAL AGREEMENT HAS BEEN RECEIVED.

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✅ Visitation Information
Date you wish for visitation or services to start?

MonthDayYear
Date
Would you like staggered arrival and departure times to ensure that the visiting and custodial parties do not see or interact with each other before or after the visit? (This option is often used when there is a history of conflict, safety concerns, or a court order requiring no contact between parties.)

YesNoDoes not apply
Where will visitations take place according to the Court Order or mutually agreed upon by the parties?

In-Office (Willow Park, Tx)Community location (ex: Public park)Residential homeVirtualPhone visit
If a community location or residential home is preferred (and permitted by the court order), please indicate your preferred location (City/County):
How often will visitations take place, according to the court order or as agreed upon between the parties? (ex: 1st, 3rd, weekends for 2hrs)
If visitation takes place in a home, is the environment safe for both the child and the supervisor? If both parties do not agree on the safety of the location, a home inspection may be required.

Yes, the home is safe and I have no concernsNo, the home is not safe and I have concernsA home inspection needs to be completed prior to the first visitationThis question does not apply
Are there additional people who may attend the visitation and are approved in the court order (ex: Grandparent, sibling, step parent..)?
How will the children be transported to the visitation location? Ensure that the custodial parent is informed and has agreed to the transportation arrangements.

Custodial parent or guardian will drive themCPS will bring to the locationFriend or relative will drive themThis question does not apply
Honest summary that led to supervised visitation being ordered by the court: *
✅ Child(ren) Information
What are the child’s names, ages, and any special needs?*
Has the child expressed any fear or reluctance about visitation?
Does the child have any allergies, medical conditions, or medications we should be aware of?
Have there been any current or past threats or attempts to flee with the child? If YES, please briefly explain.
Are there any restrictions regarding communication or physical contact between the visiting parent and the child(ren)? (Explain)
Does the COURT ORDER include any restrictions on the visiting party taking photos or videos during visitation?
When was the last time the child(ren) visited with the visiting parent? Month and Year.
✅ Parent/Guardian Information
Are all parties in full compliance with all court-ordered requirements, including but not limited to protective orders, mandatory drug testing, and any other conditions outlined by the court or legal agreements?
Has the custodial or non custodial parent been arrested for any reason within the last 12 months? If so, please list the exact charges and arresting agency.
Are any involved parties registered sex offender?*

YesNo
Is a CURRENT / VALID Protective Order or No Contact Order in place ?*

YesNo
If a protective order or no-contact order is in place, please provide a brief summary of its restrictions (e.g., must maintain a distance of at least 100 yards).
Upload current court orders, protective orders, police reports, or other documents you feel are relevant.

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✅ Consent & Acknowledgments
Communication Between Parties: Safe Time does not facilitate communication, exchange messages, or negotiate between parties. As a neutral third party, we do not represent or advocate for any individual involved in the case. It is each participant’s responsibility to manage their own communication regarding visitation arrangements.In most cases, it is the non-custodial parent’s duty to confirm dates, times, and locations directly with the other parent, as outlined in the court order. If communication is not possible or appropriate, parties should consult their legal representative for guidance..*

Yes, I understand and agree
Supervised visitation is billed at $65/hour for in-office visits and $85/hour for off-site visits (2-hour minimum required for off-site; travel fees may apply). For visits involving more than two children, an additional $20/hour will be applied. All appointments must be paid in full at least 3 days in advance to secure your scheduled time.*

Yes, I understand and agreeN/A
Court Appearance & Records Request Policy: Please be advised that this provider and its affiliates charge a $1,000 flat fee to appear in court on your case. This includes up to four (4) hours of total time for preparation, travel, waiting, and testimony. Additional time beyond four hours will be billed at $250 per hour, including all related activities.Requesting court testimony or documentation does not mean we represent, support, or advocate for either party. As a neutral third party, we provide factual observations only and do not offer expert opinions, legal recommendations, or therapeutic assessments.If you intend to use our documentation in legal proceedings, you are strongly encouraged to request certified business records in advance. Whenever possible, records should be used in place of live testimony.*

Yes, I understand and agree
Do you understand that visits will be monitored and documented, and that these written or digital records may be shared with the court or other authorized parties upon request?*

Yes, I understand and agree
Video and Body Camera Use: Safe Time Supervised Visitation may use video or body-worn cameras during visits to help ensure safety and provide accurate documentation. The decision to record is at the discretion of the provider and is not guaranteed for every visit. Visitors cannot request or refuse video recording.If you request a copy of video footage, a fee of $30 per visit will apply to cover time, storage, and secure handling.Example: Requesting footage from 2 visits = $60 (2 x $30).By selecting YES below, you acknowledge and understand the following:Recordings are for documentation purposes only.Videos are not private and may be shared with the court or attorneys upon request.All video recordings remain the property of Safe Time Supervised Visitation.*

Yes, I understand and agree
Do you agree to avoid speaking negatively about the other parent, family members, court matters, or any adult topics during visitation?*

Yes, I understand and agree
Do you understand that physical discipline of any kind is strictly prohibited during visits?*

Yes, I understand and agree
Do you agree that it is your responsibility to notify the provider of any legal updates, restraining orders, safety concerns, or incidents that may impact visitation?This includes but is not limited to changes in custody orders, protective orders, or any circumstances that could affect the safety or structure of the visit.*

Yes, I understand and agree
Do you understand that all communication with the provider must remain respectful and professional? Safetime is a neutral provider of supervised visitation. Providers are not your friends, not therapists, and are there to document observations only.*

Yes, I understand and agree
Do you understand that if any unsafe or inappropriate behavior occurs, the visit may be terminated immediately?*

Yes, I understand and agree
Do you acknowledge that visits FIRST COME, FIRST SERVIED, must be scheduled and paid in advance and that missed or canceled visits are non-refundable?*

Yes, I understand and agree
Do you authorize the provider to seek emergency medical treatment for your child if necessary and you cannot be reached?*

Yes, I authorize medical care consent to Safe Time Supervised Visitation and or all agents, in the event I can not be reached.No
Consent & Acknowledgment of Provider’s Role: I understand and acknowledge that Heather D. Hedrick, Craig Hedrick, other associates, and/or Safe Time Supervised Visitation are not attorneys and do not provide legal advice. Any statements, opinions, or interpretations of the court order made by the provider are based solely on professional judgment for the purpose of facilitating visitation in the best interest of the child, and should not be interpreted as legal counsel. By checking the box below, I agree to hold the provider and affiliated parties harmless from any liability, claims, or misunderstandings that may result from such interpretations. I further acknowledge that it is my responsibility to seek clarification or modification of the court order through appropriate legal channels if needed.*

Yes, I understand and agree
Consent & Acknowledgment of Neutrality: I understand and acknowledge that Heather D. Hedrick, Craig Hedrick, other associates, and/or Safe Time Supervised Visitation serve as neutral third-party providers. The provider does not take sides, represent, or advocate on behalf of either parent or party. All actions, comments, and decisions are made with the intent to support the best interest of the child and ensure a safe, structured environment during visitation.*

Yes, I understand and agree
Consent & Acknowledgment of Communication Boundaries: I understand that Safe Time Supervised Visitation is not responsible for facilitating communication between parties unless explicitly assigned as the court-appointed Case Manager. The provider will not serve as a messenger, mediator, or go-between for parents or guardians. All necessary coordination must occur through appropriate legal channels or the appointed Case Manager, if applicable.*

Yes, I understand and agree
Drug & Alcohol Testing Consent and Acknowledgment: I understand that pre-visitation drug and/or alcohol testing may be required at the discretion of Safe Time Supervised Visitation or by court order. Testing may include breathalyzer, urinalysis, or saliva-based methods. I agree to comply with testing when requested and understand that: Failure or refusal to court ordered testing may result in cancellation or denial of visitation. Test results may be shared with attorneys, the court, or the other party if required. I am responsible for any associated fees at the time of testing. I release Safe Time and its staff from any liability related to testing procedures or outcomes. By signing below, I consent to this policy as a condition of participation in visitation services.*

Yes, I understand and agreeN/A - No order exists
LIMIT OF CONFIDENTIALITY

Please be advised that communications, interactions, and activities during supervised visitation are not protected by any legal privilege of confidentiality. All visits are monitored and documented, and as such, there is no expectation of privacy for either party during visitation.

While some personal identifying information—such as phone numbers and addresses—may be redacted prior to releasing documentation, the overall content of visitation notes may be shared with the court, attorneys, or other authorized parties upon request.

By entering your name below, you acknowledge that you have read and understand the limitations of confidentiality and accept that supervised visitation is a monitored, documented process and not a private or confidential service.
Hold Harmless & Liability Waiver

By entering your name and acknowledging this agreement, you agree to fully release, indemnify, and hold harmless Heather D. Hedrick, Craig Hedrick, associates, contractors, and Safe Time Supervised Visitation from any and all liability, including but not limited to civil or criminal claims, lawsuits, damages, losses, or actions arising from or related to:
- Supervised visitation services
- Observations and documentation of behavior or conduct
- Reports, written summaries, or verbal communications
- Email correspondence, text messages, and phone conversations
- Scheduling or rescheduling of visits
- Suggested visitation environments, locations, or accommodations
- Third-party involvement or referrals
- Emotional or psychological outcomes from visitation
- Interpretations of the court order or professional judgment
- Accidental injury, illness, or death occurring during or in connection with supervised visitation
- Any decisions made in good faith in the best interest of the child
This waiver applies regardless of the outcome of legal proceedings or the opinions of either party. You acknowledge that supervised visitation is a monitored, non-confidential service, and that all interactions are documented in good faith with transparency and neutrality. You further agree that no statements or actions made by the provider shall be construed as legal advice or grounds for legal action.
Do you have any questions?
Typing your full name in the Jotform intake form constitutes a legal electronic signature under the U.S. E-SIGN Act.*
Please upload a photo of your government-issued ID to verify your identity. This helps us confirm that you are the authorized individual associated with your case. All information on your ID will be kept strictly confidential*

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I certify that I am the person named above and that all information provided is true and accurate. I understand that providing false information may result in service denial or legal consequences.*

Yes
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New Client Registration Form

Please answer every question as thoroughly and accurately as possible, even if it doesn’t seem to apply. Incomplete forms slow down the process for everyone.

✅ Contact Information

✅ Visitation Information

✅ Child(ren) Information

✅ Parent/Guardian Information

✅ Consent & Acknowledgments